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Patient Assistance Information

MYOBLOC Patient Assistance Program

Phone : 888-461-2255 Ext 3
Fax: 888-343-3275
> Patients must be uninsured, be at or below 350% of the Federal Poverty Level, have Cervical Dystonia and be a US citizen.
Who Can Apply
> Patients or healthcare providers can call to have an application faxed or mailed. It can also be completed online or downloaded.
> Doctors must complete a section and sign. Patients must complete a section, sign, attach proof of income and attach other requested documentation.
> Not specified
Ship To
> Not specified
Includes Support for This Drug
NOTE: Linked drugs are available for Prescribers to Apply Online now.
Click drug logo or drug name to start online application.
Myobloc (botulinum toxin type B)
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
Download printable Form
(Requires Acrobat Reader